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> T APPLICATION FOR PERMI SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described, This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Inh Add,.,, '�¢lo _3 /� l �/F_ .P�,('rE /2L� C r , i ,,. c > P KA I hereby certify that I have prepared this application and that the,work will be dope in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health -District. 1 1 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call all required inspections. Complete drawing on reverse side. - ,L Signed X <�F _ ��s� Title: �S �is2>LdT Date: I / - FOR DEPAR ;USE ONLY Application Accepted by w 11 Date Area D Pit or Grout Inspection by �— Date Final Inspection by Date ` Additional Comments: Ni ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO I AMOUNT DUE I AMOUNT REMITTED I CASH I RECEIVED BY I DATE I PERMIT NO. FH 11-24 (RFV 10It111 1-7-> l (�(� I I IL� / -7 !r-- 1 11:7:'-1 1 OI t s m �U Owner's NameC�/U/U��/VQ Adess �� firms/L�IJ.Ln /C� Phone Contractor's Name/%�i�%%�% 5 �(%f%%t�� License No. /Ty/r� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Z ieEPA��E'11JySTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump S Lei— H. P. S State Work D" Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size i Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' I hereby certify that I have prepared this application and that the,work will be dope in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health -District. 1 1 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call all required inspections. Complete drawing on reverse side. - ,L Signed X <�F _ ��s� Title: �S �is2>LdT Date: I / - FOR DEPAR ;USE ONLY Application Accepted by w 11 Date Area D Pit or Grout Inspection by �— Date Final Inspection by Date ` Additional Comments: Ni ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO I AMOUNT DUE I AMOUNT REMITTED I CASH I RECEIVED BY I DATE I PERMIT NO. FH 11-24 (RFV 10It111 1-7-> l (�(� I I IL� / -7 !r-- 1 11:7:'-1 1 OI t s m